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Based on observation and interview, the Facility failed to maintain the smoke resistance of smoke barriers by sealing the space between penetrating items such as conduit, tubing and internet (IT) cables through the smoke barrier with a material capable of maintaining the smoke resistance of the smoke barrier in accordance with 8.3 in 2 of 11 areas observed. The failed practice had the potential to affect all patients, staff and visitors because the space between the penetration and the smoke barrier would allow smoke to pass from one compartment to the next. The Facility had a census of four patients on 05/19/2015. The findings were:

A. During a tour of the Facility on 05/20/2015 at 0952, observations revealed two IT cables had penetrated the smoke barrier in the smoke barrier above the restroom near the laboratory. The Facility failed to seal penetrations made by the conduit through the smoke barrier with a material capable of maintaining the smoke resistance of the barrier. This was confirmed by the Director of Maintenance at the time of the tour.

B. During a tour of the facility on 05/20/2015 at 0958, observations revealed on penetration made by Electrical Metallic Tubing conduit in the fire rated wall above the lay-in ceiling near the entrance to the laboratory. The Facility failed to seal the penetrations made through the smoke barrier with a material capable of maintaining the smoke resistance of the barrier. This was confirmed by the Maintenance Director at the time of the tour.

Based on observation and interview, it was determined the Facility failed to maintain a minimum of three feet working space in front of one of three electrical panels in the room labeled "storage", near the Family Room, as required by NFPA 70, Section 110.26. The failed practice had the potential to affect all patients, staff and visitors due to the inability of quick access to the electrical equipment in the event of an emergency. The Facility had a census of four patients on 05/19/15. The findings follow:

A. On a tour of the Facility, on 05/19/15 at 0918, with the Maintenance Director, the area in front of the electrical panels in a room labeled STORAGE was used to store items that did not allow free access to one of three electrical panels.

B. At the time of the observation, the Maintenance Director verified the area in front of the electrical panel was not clear.

Based on observation and interview, the Facility failed to maintain the smoke resistance of smoke barriers by sealing the space between penetrating items such as conduit, tubing and internet (IT) cables through the smoke barrier with a material capable of maintaining the smoke resistance of the smoke barrier in accordance with 8.3 in 2 of 11 areas observed. The failed practice had the potential to affect all patients, staff and visitors because the space between the penetration and the smoke barrier would allow smoke to pass from one compartment to the next. The Facility had a census of four patients on 05/19/2015. The findings were:

A. During a tour of the Facility on 05/20/2015 at 0952, observations revealed two IT cables had penetrated the smoke barrier in the smoke barrier above the restroom near the laboratory. The Facility failed to seal penetrations made by the conduit through the smoke barrier with a material capable of maintaining the smoke resistance of the barrier. This was confirmed by the Director of Maintenance at the time of the tour.

B. During a tour of the facility on 05/20/2015 at 0958, observations revealed on penetration made by Electrical Metallic Tubing conduit in the fire rated wall above the lay-in ceiling near the entrance to the laboratory. The Facility failed to seal the penetrations made through the smoke barrier with a material capable of maintaining the smoke resistance of the barrier. This was confirmed by the Maintenance Director at the time of the tour.

Based on observation and interview, it was determined the Facility failed to maintain a minimum of three feet working space in front of one of three electrical panels in the room labeled "storage", near the Family Room, as required by NFPA 70, Section 110.26. The failed practice had the potential to affect all patients, staff and visitors due to the inability of quick access to the electrical equipment in the event of an emergency. The Facility had a census of four patients on 05/19/15. The findings follow:

A. On a tour of the Facility, on 05/19/15 at 0918, with the Maintenance Director, the area in front of the electrical panels in a room labeled STORAGE was used to store items that did not allow free access to one of three electrical panels.

B. At the time of the observation, the Maintenance Director verified the area in front of the electrical panel was not clear.